Overview of Care Plans
By: Laura Velasco BSN, RN, HACP
Nursing care plans… you either love them or hate them. But no matter what your opinion, they are a vital tool for how care is developed and maintained throughout the hospital stay. In nursing school, we wrote care plans and nursing diagnoses on everything under the sun. The point of the exercise is to develop a way of critical thinking about the process of nursing care.
A nursing care plan is a formal process that includes correctly identifying existing patient needs, as well as recognizing potential needs or risks. The patient’s nursing care needs (not solely those needs related to the admitting diagnosis) are what guides this document.
Nursing care plans make it possible for interventions to be recorded and their effectiveness assessed. They provide continuity of care, safety, quality care, and ensure compliance. They also provide a means of communication among nurses, their patients, and other healthcare providers to coordinate the delivery of care to achieve health care goals.
Only RNs can develop the nursing care plan and make changes, although LPNs can contribute suggestions. Care planning and evaluation require critical thinking skills, including the ability to analyze information, consider underlying medical conditions, and integrate that information into the overall picture of the patient’s health status. These skills are taught in nursing school but are not included in the LPN curriculum.
In general, the nursing staff develops, and keeps current, a nursing care plan for each patient. The nursing care plan may be part of an interdisciplinary care plan. While CMS does not indicate that care plans be updated on a routine basis, the nursing care plan must be updated or revised in response to ongoing assessment findings. The things to ensure are a part of the care plan include:
Overall, it is a fluid, active document that can be a very useful tool if utilized correctly.